Application for Employment AuthorizationFile Online

• Legal Form Number: I-765
• Section: Citizenship and Immigration Services (United States of America)
• Issuer: Citizenship and Immigration Services (United States of America)

Page 1 of 7Form I-765 Edition 10/31/22

Authorization/Extension

Valid Through

Authorization/Extension

Valid From

For

USCIS

Use

Only

Application For Employment Authorization

Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS

Form I-765

OMB No. 1615-0040

Expires 10/31/2025

START HERE - Type or print in black ink.►

Part 1. Reason for Applying

Your Full Legal Name

1.a. Family Name

(Last Name)

1.b. Given Name

(First Name)

1.c. Middle Name

Initial permission to accept employment.

I am applying for (select only one box):

Replacement of lost, stolen, or damaged employment

authorization document, or correction of my

employment authorization document NOT DUE to

U.S. Citizenship and Immigration Services (USCIS)

error.

NOTE: Replacement (correction) of an employment

authorization document due to USCIS error does not

require a new Form I-765 and filing fee. Refer to

Replacement for Card Error in the What is the

Filing Fee section of the Form I-765 Instructions for

further details.

1.a.

1.b.

Renewal of my permission to accept employment.

(Attach a copy of your previous employment

authorization document.)

1.c.

Action BlockFee Stamp

Select this box if Form G-28

is attached. Attorney or Accredited Representative

USCIS Online Account Number (if any)

To be completed by an attorney or

Board of Immigration Appeals (BIA)-

accredited representative (if any).

Part 2. Information About You

Other Names Used

Provide all other names you have ever used, including aliases,

maiden name, and nicknames. If you need extra space to

complete this section, use the space provided in Part 6.

Additional Information.

2.a. Family Name

(Last Name)

2.b. Given Name

(First Name)

2.c. Middle Name

3.a.

Middle Name4.c.

Given Name

(First Name)

4.b.

Family Name

(Last Name)

4.a.

Family Name

(Last Name)

3.b. Given Name

(First Name)

3.c. Middle Name

Remarks

A-

Alien Registration Number